“How are my numbers?”

It’s a question that I get daily from my patients, often on several occasions. Patients will call and ask for a copy of their lab report or, if they are enrolled in our online portal program, after they check their values on their computer. “Oh my God, what does RDW stand for?” or “Why is my sodium so high?” Sometimes, it’s due to nothing more than not drinking enough water!

As rheumatology nurses, we are trained to always evaluate a patient’s lab results and often withhold refills or infusions if the patient does not comply with having labs checked in a timely manner. We care for the whole patient—not just numbers or joint counts, but the entire body. Inflammatory diseases—and especially rheumatoid arthritis (RA)—can affect arteries, lungs, blood vessels, and many other systems. Our common treatments have potential side effects such as infection, liver toxicity, and neutropenia, just to name a few, that we also need to be mindful of.

Education of our patients is key to successful management of their disease. Patients may know they have RA, but they rarely remember all the ramifications of the disease. When we weigh a patient and a scent of cigarette smoke is obvious, it’s a good time to remind patients that RA can and does affect the lungs. The usual response I get is something like, “Oh, I thought it just affected my bones.”

So when patients ask me, “How are my labs?” I take that as an opportunity to do more than simply review their numerical values with them. My typical answer to that question, therefore, is “Well, how are you?” I often need to explain to patients that we do not treat pieces of paper, but that we treat people. It’s often safe to assume that a patient wants to avoid coming in for an office visit when they call and ask about “their numbers.”

Numbers, unfortunately, don’t often tell the full story with our patients. Without a clinical correlation, without us seeing and touching our patients, numbers offer an incomplete window into overall well-being.

Lab values can, of course, be incredibly useful. For instance, they can show whether a medication is causing liver toxicity, which leads to a phone call asking the patient to adjust their dose of methotrexate or reduce the frequency in which they take a “harmless over‑the‑counter” medication such as ibuprofen. Even during these calls, I reinforce the need for the patient to come in for their next office visit to talk about their overall well-being.

Let me relay a brief anecdote that demonstrates the value of looking past the numbers.

Jan is a 35-year-old female who came to our office 18 months ago with typical symptoms of joint pain and morning stiffness. She had a positive family history of RA through her maternal grandmother. Upon her initial presentation, we ran the usual battery of laboratory tests. Her C-reactive protein was sky high, at 30.8 (normal is between 0 and 5.0). Her rheumatoid factor (RF) was also significantly elevated – RF IgM of 302 (normal range: 0-25), RF IgG of 65 (normal range: 0-20), and RF IgA of 205 (normal range: 0-35)

She was diagnosed with RA and started on a regimen of daily methotrexate (15 mg) and leflunomide (10 mg). Based upon Treat to Target guidelines, we set remission as our treatment goal.1

Eighteen months later, we appear to be on the right track. Jan’s C-reactive protein levels have normalized. She claims to have no morning stiffness or joint swelling. Her most recent Health Assessment Questionnaire score is 0.0. Even her x-rays appear normal with no evidence of erosive disease. Obviously, I was thrilled with her improvement and congratulated her on her success and adherence to our treatment regimen.

But alas the “performance” is never over! Jan’s RF immunoglobulins show that her RA remains quite active in her blood, so although her disease appears to be in remission from a qualitative perspective, we need to remain vigilant to keep her disease activity under control. Additionally, Jan has an upcoming wedding, so we have begun discussions of potential adjustments to her medication regimen if she hopes to become pregnant in the near future.

I have consistently ensured Jan that we are a team, and that as long she remains in adherence to future scheduled visits, medications, and lab tests, we can hopefully continue to keep her days as symptom-free as possible.

As medicine has become increasingly compartmentalized, it is challenging for those of us in rheumatology to manage a patient’s entire body system and remain alert for key changes that may signal likely changes in a patient’s overall health and quality of life. With a growing arsenal of medications at our disposal, being aware of and monitoring for likely side effects is a constant vigil. Talking to and asking questions of our patients, and making sure that they come in to talk to us face-to-face and not just on the phone, remains paramount to optimizing outcomes.

AUTHOR PROFILE:
Jacqueline Fritz, RN, MSN, CNS, RN-BC, is Owner and Coordinator of Education at the Medical Advancement Center in Cypress, CA. Her primary responsibility is working as an advanced practice nurse for a large rheumatology practice where she is involved in patient visits, research programs, and infusion center coordination. In addition, she enjoys speaking, teaching, and learning about immunology.

References
1. Smolen JS, Breedveld FC, Burmester GR, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016;75(1):3-15.